Developing and Submitting Standardized Nomenclature NANDA and NOC

Presented by: Jennifer Hafner RN, BSN, PCCN, TNCC and Joan Klehr RNC, MPH Aspirus Wausau Hospital

Aspirus Wausau Hospital

Regional Area

Aspirus Wausau Hospital

Who we are Today
321 Licensed Beds 2435 Employees 645 Physicians, Dentists, Podiatrists, Allied Health Practitioners 59 Specialties Not for Profit Tertiary Care Referral Community Based Family Practice Residency Program Center of Excellence

Aspirus Wausau Hospital FY 08

Patient Days Discharges Average Daily Census Outpatient Registrations Babies Delivered Wausau Heart Institute Open Heart Procedures Emergency Department Visits 58,669 13,497 160 74,802 1,092 625 25,145

Aspirus Wausau Hospital

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Recognitions

Objectives

Discuss Applicability of Current Nomenclature to the Acute Care Setting Explain the Process for Developing and Submitting Diagnoses Explain the Process for Developing and Submitting Outcomes

Objectives
Identify Diagnoses and Outcomes Created and Revised and Articulate Rationale Discuss Plans for Using Nanda, NIC, and NOC in use of Nursing Protocols and Patient Education

Standardized Nomenclature (SNL) in Acute Care

SNL in the Acute Care Setting

Risk for Versus Actual Diagnoses Diagnoses accepted
Risk for Ineffective Cardiopulmonary Tissue Perfusion Risk for Ineffective Cerebral Tissue Perfusion Risk for Ineffective Gastrointestinal Tissue Perfusion Risk for Ineffective Renal Tissue Perfusion Ineffective Peripheral Tissue Perfusion Risk for Shock Risk for Electrolyte Imbalance Dysfunctional Gastrointestinal Motility Risk for Dysfunctional Gastrointestinal Motility

SNL in the Acute Care Setting

Outcomes For Acute Care
Shock
Tissue Perfusion: Cellular

Peripheral Neuropathy
Neurological Status: Peripheral

Safety
Safe Healthcare Environment

Evidenced-Based Data
Literature Search
Current References in APA Format

Reference Sources
Evidenced-based Literature Linked to Pertinent Factors or Characteristics

Not Necessary to Perform Research

Revision versus New Term

When to Submit a Revision
Update a Diagnosis or Outcome Update for Electronic Medical Record

When to Submit a New Term

No Diagnosis, or Outcome Fits your Patient You Find a Need

Development and Submission

Literature Review Review of Requirements Development Review Submission Editorial Review Re-Submission

Nursing Outcomes Classification (NOC) Requirements

Developing an Outcome 1. Define the outcome as a variable patient/client state, behavior, or perception that is responsive to nursing interventions 2. Label (name): should be concise 3. May use colons to make more specific 4. Labels should describe concepts that can be measured along a continuum 5. Labels should be neutral and not stated as goals.

NOC Requirements
6. Identify indicators (signs and symptoms) specific to the outcome. Indicators must be able to be used to determine the status of the patient/client. 7. The definition should be a brief phrase that defines the concept and encompasses the indicators. 8. References in APA format
Nursing Outcomes Classification 4th Edition 878-879

NOC Revisions
Feedback on a Outcome
Paragraph of rationale, and suggested changes

Feedback on a Measurement Scale

Provide experience with scale and suggestions

Feedback on Linkages to NANDAs Feedback on Core Outcomes by Specialty

NOC Submission

Nursing Diagnosis (NANDA) Requirements

Label (Name)
Reflects the Definition and Defining Characteristics

Definition: Supported by References Defining Characteristics

Use for Actual, Health-Promotion, and Wellness Diagnoses

NANDA Requirements
Risk Factors: Risk for Diagnoses Only Related Factors: Actual Diagnoses Only Nursing Interventions (Nursing Intervention Classification: NIC) Need Nursing Outcomes (NOC) Only 3 List Each Risk Factor, Related Factor, NIC, and NOC individually!!!!!!!!

NANDA Requirements
Bibliography
APA Format Numbered References Write the Number of Each Reference Next to the Definition, Each Defining Characteristic, Risk Factor, and Related Factor!

NANDA Submission

NANDA Review Process

Full Review Process 1. Initial review by diagnosis committee member, make changes, re-submit 2. Committee review with recommendations 3. After changes, review with recommendations and voting by NANDA-I members with feedback Expedited Review Process 1. Initial review by diagnosis committee member, make changes, re-submit 2. Committee review with recommendations 3. After changes, review with recommendations to the NANDA-I Board of Directors for approval

www.nanda.org/DiagnosisDevelopment/ DiagnosisSubmission/SubmissionReview.aspx

NANDA Review Process

Full Review Process 4. Make changes 5. Diagnosis goes to NANDA-I Board of Directors for approval 6. Post on website as approved 7. Assimilate into NANDAI Taxonomy II and NNN Taxonomy of Nursing Practice 8. Publication Expedited Review Process 4. Post on website as approved 5. Assimilate into NANDA-I Taxonomy II and NNN Taxonomy of Nursing Practice 6. Publication

www.nanda.org/DiagnosisDevelopment/ DiagnosisSubmission/SubmissionReview.aspx

References in APA Format

Ackley, B. J., Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care (7th ed.). St Louis: Mosby. Epic Systems Corporation (2002). (Epic 2002 MU4) [Computer software]. Verona, WI: Epic Systems Corporation McCloskey Dochterman, J., & Bulechek, G. M. (Eds.). (2008). Nursing interventions classification (5th ed.). St. Louis: Mosby.

Application to Clinical Practice

Application to Clinical Practice

Link NANDA, NIC and NOC to Hospital Policies and Protocols Clinical Decision Support
Suggest Diagnoses for Care Plan Based on Assessment Findings Critical Thinking

Questions?

Bibliography
Epic Systems Corporation (2007). (Epic Spring 2007 IU3) [Computer software]. Verona, WI: Epic Systems Corporation. Moorhead, S. , Johnson, M., & Maas, M. (Eds.). (2008). Nursing outcomes classification (4th ed.). St. Louis: Mosby. North American Nursing Diagnosis International. (2007). Nursing diagnoses: Definitions & classification 2007-2008. Philadelphia: NANDA International.

Bibliography
North American Nursing Diagnosis Association. (n.d.). NANDA-I diagnosis submission form for new and revised nursing diagnoses. Retrieved October 6, 2008 from http://www.nanda.org/Portals/0/word_docs/diagnosis_submissio n_form.doc North American Nursing Diagnosis Association. (n.d.). Protocol for submission or revision of diagnoses. Retrieved September 25, 2008 from http://www.nanda.org/DiagnosisDevelopment/DiagnosisSubmis sion/SubmissionReview.aspx North American Nursing Diagnosis Association. (n.d.). Submission guidelines: New and revised nursing diagnoses. Retrieved September 25, 2008 from http://www.nanda.org/DiagnosisDevelopment/DiagnosisSubmis sion/PreparingYourSubmission.aspx